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8 A M E R I C A N J O U R N A L O F M E S O T H E R A P Y

ABSTRACT

BACKGROUNDSubjects with localized fat deposits commonly receive suc-

tion lipectomy as a cosmetic procedure. A new office proce-

dure for the correction of superficial fat deposits was applied

in 50 patients by the injection of phosphatidylcholine (PC).

METHODSThe method consists of using a 30-gauge, one-half-inch

insulin needle to inject approximately 5 mL (250 mg/5 mL) of PC

into the fat, distributing it evenly in a 80-cm² area. Pre- and

post-treatment photographs were taken for technical planning

and analysis of the results long-term.

RESULTSA clear improvement occurred in all 50 patients, with marked

reduction of the fat deposits without recurrence over a 2-year

follow-up period, and no subsequent weight gain occurred.

CONCLUSIONSThe injection of PC into fat deposits is a simple office proce-

dure that can sometimes postpone or substitute for surgery

and liposuction.

INTRODUCTIONA new and simple technique for treating fat deposits by the

injection of phosphatidylcholine (PC) is described in this article.

Liposuction is one of the most commonly performed cos-

metic procedures for the treatment of minimal to moderate lo-

calized fat deposits.1 Adverse effects and surgical risks are a

concern to both physician and patient when treating these

deformities by surgical resection or liposuction. The safety of

the procedure, patient selection, complications, and results

have been addressed elsewhere.

I have been using this new PC injection technique since

1995, achieving very good results. At first, only fat pads2 were

the focus of this procedure, which was introduced to the sci-

entific community at the Dermatologic Brazilian Congress in

1999 and published by Dermatologic Surgery in April 2001.

Today, localized fat is the target of this treatment, and due to

the excellent results and minimal complications or adverse ef-

fects, this procedure has proved to be extremely effective in

contouring and remodeling superficial fat areas in the arms,

abdomen, thighs, and neck.

Pre- and post-procedure photographs of the cases studied

document this new method. Patient satisfaction and the ab-

sence of recurrence were the best evaluators of the results.

The intervals will be discussed further in the methods section.

The procedure is simple and can be done in the office.

PHOSPHATIDYLCHOLINE (Lipostabil)Various studies have reported the use of PC (Lipostabil)

for the reduction of systemic levels of cholesterol and trig-

lycerides.3,4 PC is a bile component and is responsible for

the emulsification of dietary lipids.5 However, a study by

Bobkova6 verified that on increasing PC, cell membranes

showed the following effects: receptor properties im-

proved, sensitivity to insulin was augmented, and lipoly-

sis was accelerated. There was a marked reduction of

atheromatous plaques and the levels of aortic cholesterol

without a reduction in plasma cholesterol levels. In other

studies Lipostabil was employed intravenously in patients

with cardiac ischemia.7

Patrícia Guedes Rittes, MDClínica Patrícia RittesSão Paulo, SP, Brazil

THE USE OF PHOSPHATIDYLCHOLINEFOR CORRECTION OF LOCALIZED FATDEPOSITS

9S C I E N C E S E C T I O N

The objective of this study is to improve corporal contour

by reducing fat deposits. Our intention was to obtain better

cosmetic results in those patients unsuitable for or wanting to

avoid surgery.

Preoperative Analysis and Patient SelectionPreoperatively, it is essential to discuss the patient’s expec-

tations objectively to ensure they are realistic and achievable.

Evaluation of the size and location of the fat deposits is neces-

sary. The individual evaluation of each case is extremely im-

portant; patients must be informed of the results that can be

reasonably expected with this technique, and care must be

taken not to promote false expectations.

This technique is indicated for all patients with fat deposits

not due to obesity and especially for those patients for whom

liposuction or a surgical procedure is impossible due to surgi-

cal risks. When selecting patients, those of ideal weight (not

obese) and only those with localized fat deposits were chosen.

In some cases a patient had some fat excess only in the area

above the waist but with ideal weight from the waist down (for

example, patients on chronic corticosteroid therapy). Only pa-

tients over 25 years old were accepted because until this age

the organic metabolism works at 100% of its capacity.

The patient should be informed that this method treats only

localized fat deposits, which are different from obesity and

loose skin.

Contraindications� Obesity. This procedure is indicated only for small fat de-

posits; it is not a slimming treatment

� Patients under 25 years old (explained above)

� Pregnancy

The use of PC should be restricted to small, localized fat

deposits, with the same indications as for liposuction. It is not

indicated for obese patients because it is not a slimming treat-

ment, with a few exceptions, such as alterations of the body

contour or obesity caused by a chronic use of systemic corti-

costeroid therapy.

Informed consent was obtained from all individuals, and

this study conformed to guidelines of the 1975 Declaration of

Helsinki.

MATERIALS AND METHODSStart the procedure with the patient seated or lying down,

depending on the site to be injected. The method consists of

using a 30-gauge, one-half-inch insulin needle to inject ap-

proximately 5 mL (250 mg/5 mL) of PC into the fat deposits,

distributed evenly in an 80-cm² area. The solution is injected

into the fat deposits in the abdomen, neck, arms, or thighs (the

portion of the leg between the hip and the knee), based on

individual needs. Local anesthetics are unnecessary.

Immediately after application, infiltrative edema occurs, with

local erythema and a mild burning sensation, usually lasting

for 15 minutes. Swelling and redness at injection sites occur

during the next 6 hours and last for about 72 hours. Nodule

formation and hematomas can occur and may take 15 to 30

days to resolve.

We studied 50 patients, 40 women and 10 men, ages 25 to 60

years, with fat deposits of various sizes. Injections were ap-

plied at intervals of 15 days as follows:

— 35 cases with 4 treatments (70%)

— 10 cases with 2 treatments (20%)

— 5 cases with 1 treatment (10%)

This time interval was necessary for the edema from the

injection to completely disappear. The need for additional in-

jections was determined by the fat volume.

The solution is evenly distributed. By observing and men-

tally calculating, the area to be treated is divided in 6 parts, and

then injected with approximately 0.8 mL in each part, distribut-

ing the remaining 0.2 mL of substance in areas as needed. It is

apparent that the substance remains in the treated area be-

cause immediately after injection, localized swelling and some

erythema occur for about 48 hours, but not invading any other

distant site.

Tape measurements were not done due to the difficulty in

using a tape measure precisely; if not placed accurately (above

or below the previous tape measurement) measurements are

imprecise and not comparable. Also, in the premenstrual pe-

riod, women may have body measure changes due to fluid

retention, which is not significant. That is why photographs

were taken, to give a more accurate visualization of before and

after status.

The number of treatments depended on physician and pa-

tient satisfaction. According to the results obtained, due to

the appearance of the remaining fat deposits, the physician

decided the need for further injections.

ComplicationsNo complications were observed beyond the symptoms

described above, such as bruises, edema, and erythema that

lasted from 48 to 72 hours, and the appearance of

postinflammatory nodules, which disappear within 30 days at

the most. No atrophy occurred.

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10 A M E R I C A N J O U R N A L O F M E S O T H E R A P Y

FIGURES

1a. A 29-year-old patient with

local fat deposits, before

procedure.

1b. Same patient after 1 appli-

cation of phosphatidyl-

choline (PC), at 15 days.

1c. Same patient after 2 appli-

cations of PC (at 30 days).

Long-Term Follow-UpLong-term follow-up has reached 4 years, with no return of

localized fat deposits as long as there was no weight gain over

4 kg (11 pounds).

RESULTSCosmetic improvement occurred in all patients with fat de-

posits. The amount of fat reduction was not tape-measured

but photographs show the results (see Figures). Patients did

not show a return of the local fat for approximately 4 years, but

the treatment can be repeated if necessary. When there is a fat

increase, despite gaining or not gaining weight, the procedure

can be repeated. In the cases mentioned in the protocol, no

repeat treatment was performed. At this time more than 500

patients have been treated.

DISCUSSIONThe final results are similar to both liposuction and surgery.

Until now, the only treatment has been liposuction and/or sur-

gery. This study provides a simple, rapid office procedure with-

out surgical risks. The cosmetic results are satisfactory both

from the patients’ and the dermatologist’s points of view.

Patients were followed for 4 years with no return of the local

fat, as long as no weight gain over 4 kg occurred. In treating

more than 500 patients, not even a single case of atrophy or

complications were observed.

SerologySerologic studies were not done in these cases, but Bobkova

et al6 studied the effects of Lipostabil-forte containing unsat-

urated fatty acids on serum lipid concentrations, plasma and

erythrocyte lipid and phospholipid fractions, immunoreactive

insulin levels, and thyroid hormone levels in 30 patients with

coronary heart disease. During treatment a statistically signifi-

cant reduction in serum triglycerides, an increase in relative

erythrocyte phospholipid levels, and an increase in plasma

and erythrocyte PC levels were seen in all patients within 1

month and, in some patients, at 3 and 6 months. A reversal of

hyperinsulinemia and improvement of thyroid function were

also noted.6

Animal studies have shown that the maximum nontoxic

intravenous dose of lecithin (purified soya phospholipids

containing 75% to 80% PC), in mice, rats, and rabbits was 4,

2, and 0.5 g/kg, respectively.8 The maximal nontoxic subcu-

taneous dose for in mice, rats, and rabbits was 10, 4, and 1

g/kg, respectively.9

CONCLUSIONSThis technique for treating fat deposits by the injection

of phosphatidylcholine (PC) in appropriately selected pa-

tients has been shown to have the following results.

� It does not induce skin laxity.

� There is a natural postoperative appearance without a

surgical “look.”

� Surgical or anesthetic risks are eliminated. It is suitable

for patients with an intense fear of hospitalization.

� It is a rapid office procedure, eliminating the need for

hospitalization.

� Patient satisfaction is good, there are no skin scars or

irregularities, and the cosmetic results are good.

� There is less postoperative discomfort than with surgery.

I have been performing this technique for the past 4 years

without any complications. Recurrence or skin laxity was

not noted after treatment. Hopefully, this technique will be

of additional help to physicians and surgeons in the clinical

approach to these deformities that are sometimes so vexing

to patients.

11S C I E N C E S E C T I O N

2d. Same patient after 8 appli-

cations of PC

(at 120 days).

2a. A 57-year-old patient

with local fat deposits

due to cortisone

chronic use, before

procedure.

2b. Same patient after 2 ap-

plications of PC

(at 30 days).

2c. Same patient after 4 ap-

plications of PC

(at 60 days).

Patricia Guedes Rittes, MDRua Afonso Bráz, 864 conj. 72 7th FloorVila Nova ConceiçãoSão Paulo, BrazilPhone: 55.11.3045.4167Website: www.rittesliponet.comE-mail: www.prittes@terra.com.brDr Patrícia Rittes pioneered the use of phosphatidylcholineinjections, and she has been a major influence inphosphatidylcholine and mesotherapy aesthetic treatmentsworldwide.

REFERENCES1. Markey AC. Liposuction in cosmetic dermatology. Clin Exp Dermatol.

2001;26:3-5.2. Rittes PG. The use of phosphatidylcholine for correction of lower lid

bulging due to prominent fat pads. Dermatol Surgery. 2001;27:391-392.

3. Warembourg H, Jaillard J. [Clinical trial of Lipostabil in the treat-ment of diabetic angiopathy.] Lille Med. 1968 Jun-Jul;13(6):Suppl727-731. French.

4. Navder KP, Baraona E, Lieber CS. Polyenylphosphatidylcholine de-creases alcoholic hyperlipemia without affecting the alcohol-inducedrise of HDL-cholesterol. Life Sci. 1997;61:1907-1914.

5. Montgomery R, Conway TW, Spector AA. Biochemistry: A Case-Oriented Approach. 5th ed. St Louis, Mo: The CV Mosby Company;1990.

6. Bobkova VI, Lokshina LI, Korsunskii VN, Tananova GV. [Metaboliceffect of lipostabil-forte.] Kardiologiia. 1989 Oct;29(10):57-60.Russian.

7. Pogozheva AV, Bobkova SN, Samsonov MA, Vasil’ev AV. [Com-parative evaluation of hypolipidemic effects of omega-3 polyun-saturated acids and lipostabil]. Vopr Pitan. 1996;(4):31-33. Russian.

8. Nattermannn Phospholipids GmbH. Phospholipids and liposomes,Scientific Publication 2; 1995.

9. Fiume Z. Final report on the safety assessment of Lecithin andHydrogenated Lecithin. Int J Toxicol. 2001;20 Suppl 1:21-45.